Provider Demographics
NPI:1376581546
Name:HANSEN, DWAYNE M (MD)
Entity Type:Individual
Prefix:DR
First Name:DWAYNE
Middle Name:M
Last Name:HANSEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 185
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-0185
Mailing Address - Country:US
Mailing Address - Phone:208-656-8442
Mailing Address - Fax:208-656-8453
Practice Address - Street 1:381 EAST 4TH NORTH
Practice Address - Street 2:STE 100
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440
Practice Address - Country:US
Practice Address - Phone:208-656-8442
Practice Address - Fax:208-656-8453
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-02
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM8427208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID48488OtherBLUE CROSS OF IDAHO
IDCS9440OtherIDAHO STATE BOARD OF PHAR
IDM8427OtherIDAHO STATE LICENSE
IDM8427OtherIDAHO STATE LICENSE
IDBH5461950OtherDEA
IDG57658Medicare UPIN